A Muzungo's experience

IN CASE THE VIDEOS WERE NOT WORKING FOR YOU, ALL OF MY PHOTOS AND VIDEOS FOR THE BLOG CAN BE FOUND HERE. THANKS! (Nov 11, 2010)

Muzungo: Non-derogatory term in Luganda (most common tribal language here) for white person

In the last two days, I think I have really begun to understand some fundamentals of Ugandan culture and way of life in ways most muzungos who come here do not.

I took call on Saturday night until the end of Sunday morning with two of the local residents. Their shifts here run from 5pm to 5pm the next day, as opposed to the North American way of 7am to some undetermined time the following morning, or if unlucky, afternoon.

I arrived at 5pm to meet the senior resident on call, Yasin. In African fashion, he arrived 45 minutes later. He toured me around the Casualty Department (ER), the Casualty OR, and the short-stay trauma unit which is shared by all surgical services. The casualty department consists of a short hallway and a waiting room which dubs as the lobby entrance of the hospital. There is a VIP room (it is still unclear to me who gets to enter here), a resuscitation room (equipped with 2 beds, one oxygen tank, and portable suction), an X-Ray machine, maybe 4 beds for assessment, and a plaster room. The plaster room is managed only by the orthopaedic officers, and it seems the residents do not have access to it or its supplies. Orthopaedic officers are people trained for 3 years exclusively to treat closed orthopaedic injuries. They do closed reductions and casting. In Casualty, they see all ortho patients first, then send them to the short-stay ward for orthopaedic assessment. Even though we may walk by 1 or 2 people lying with open fractures in the hallway, an ortho resident will not bother assessing them until they are brought to the ward.

The short-stay ward has three sections divided by 6 feet walls. There are maybe 30 beds in here, but as many as needed can be squeezed in to the point that you almost need to crawl over beds to see someone tucked away at the back. There are never more than 2 nurses here on duty. Nurses are responsible only for administering medications, perhaps starting IVs (but residents do this too to save time), and otherwise go to see a patient only if sufficiently begged to by the resident or patient's family. Patient's families are crucial in the hospitalization process. As there are no attendants for patients, if you do not have family to help you, you do not eat, get bed sheets or have anyone to walk you to the one washroom on the ward. I am starting to notice those who do not have families are at high risk of dying. No one takes regular vital signs here or responds to calls of pain or help. This means that if you begin to feel unwell or become unstable and don't have a family member to get help for you, you will decompensate and possibly die, unnoticed.

The OR in the Casualty department has two rooms. It is staffed however, but only one team. If lucky, there maybe be two anesthetists and two nurses. Often the ortho residents are doing their cases with no assistance by nurses, and are lucky if an anesthetist pays even an ounce of attention. The OR here is also poorly stocked. The main ortho ward is not great, but here it is the pits. No drills or saws, and no implants at all. Not even plaster to maintain the reductions you do manage to achieve. The emergency OR for ortho is staffed only by the resident on call, and is used only for irrigating and debriding open fractures and stabilising them if possible. Apparently you can sometimes put pins in by hand. This weekend however, we had nothing to work with. I mean nothing. We made casts and splints out of cardboard boxes and cotton rolls. I performed a below-knee leg amputation with a dull tool, a mallet and mostly brute strength. (Yes, I do have some of that hidden somewhere.)

Although I did have access to a few more tools (uselessly dull saw, dull periosteal elevator used as an osteotome, and mallet), this is more or less all you have to work with. There is not even cautery in this ER operating room.

This is the stock room. At least it has an autoclave. the trays on the counter is all there is for instruments. Behind me is a modest stock of dressings and gloves.

The worst part about the whole system to me however, is watching people who come in with a chance of a full recovery, and yet the delays and lack of infrastructure and tools leave them with devastating results. While waiting for treatment, injuries turn into permanent disabilities and in some cases death. For instance, a man came in with an open forearm fracture. It took almost 8 hours for ortho to see him, as we were operating and there were three other people with open injuries ahead of him. On initial assessment, his nerves and arteries were working, and he was more or less well. Five hours later, lying on an cot with his arm in a cardboard splint, he had lost so much blood his tongue was white and he couldn't even hold up his head. His hand was now paralyzed and he had no pulse. He never complained. 12 hours before, we could have at least casted him, washed out his wounds and given him a chance at a functional arm, now... he is looking at an amputation if he survives at all.

Culturally, the hospital also has a lot to say about Ugandans. Children, even infants, are lovingly ignored if I can call it that. Cries are ignored, kids can walk around on their own and it seems no one watches them. One 8 year old boy with disfiguring burns to his face, was alone on his cot at least half the time. Luckily he seemed to sleep a lot. Families are large. Most women have between 5 and 10 children. Families are close, and when a member nears death, they weep loudly, wave their arms in the air, hug each other, pray, and call out to the gods for help. Interestingly however, it seems the concept of injury and its potential negative and permanent outcomes, are foreign to Ugandans. We explained to a 24 year old boy and his family that his boda-boda accident had left him permanently quadriplegic. No one wept. No one looked anxious. I can't tell if it's that they don't understand (which is what the resident thinks), or maybe they just accept it for what it is. In the last 30 years until recently, anytime you went out you risked get assaulted, raped or killed by Idi Amin's men. Perhaps Ugandans have come to grips with the fact that everyday risks await you, and often you will not recover from them.

On a much lighter note, last night I attended a show by the Ndere Troupe in Ntinda. Jackson, a PhD in biology who works on sustainable renewable resources, fisheries in particular, took me to see this group who performs songs and dances from tribes all over Uganda. I met Jackson though Lauren, a biogist who works with Martin at McGill. The show was spectacular. It took place in an open air amphitheater which was built with the help of the Austrian government. It was very interesting to hear and see the differences among tribes. Here are a few videos to give you a taste. The first one is a dance from the north which calls for peace. The women stack up to 8 or 9 clay pots on their heads and dance around. The second one is a dance from Central Uganda. The men have rattles on their legs. The third one is from Western Uganda, and the last one is also Central Uganda.

Until next time, and thanks to all of you who read my rambling memories of my days in Uganda.